Growing Up Tobacco Free: Preventing Nicotine Addiction in ...€¦ · Growing up tobacco free :...

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Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youths

Barbara S. Lynch and Richard J. Bonnie, Editors; Committee on Preventing Nicotine Addiction in Children and Youths, Institute of Medicine

http://www.nap.edu/catalog/4757.htmlhttp://www.nap.eduhttp://www.nas.edu/nashttp://www.nae.eduhttp://www.iom.eduhttp://www.nationalacademies.org/nrc/http://lab.nap.edu/nap-cgi/dashboard.cgi?isbn=0309051290&act=dashboardhttp://www.nap.edu/agent.htmlhttp://www.nap.edumailto:[email protected]://www.nap.eduhttp://www.nap.edu/v3/makepage.phtml?val1=reprinthttp://www.nap.edu/catalog/4757.html

GROWING UPTOBACCO FREE

PREVENTING NICOTINE ADDICTION INCHILDREN AND YOUTHS

Barbara S. Lynch and Richard J. Bonnie, Editors

Committee on Preventing Nicotine Addiction in Children andYouths

Division of Biobehavioral Sciences and Mental DisordersInstitute of Medicine

NATIONAL ACADEMY PRESSWashington, D.C. 1994

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Copyright © National Academy of Sciences. All rights reserved.

Growing Up Tobacco Free: Preventing Nicotine Addiction in Children and Youthshttp://www.nap.edu/catalog/4757.html


NATIONAL ACADEMY PRESS 2101 Constitution Avenue, NW Washington, DC 20418

NOTICE: The project that is the subject of this report was approved by the Governing Board of theNational Research Council, whose members are drawn from the councils of the National Academyof Sciences, the National Academy of Engineering, and the Institute of Medicine. The members ofthe committee responsible for this report were chosen for their special competencies and with regardfor appropriate balance.

This report has been reviewed by a group other than the authors according to proceduresapproved by a Report Review Committee consisting of members of the National Academy of Sci-ences, the National Academy of Engineering, and the Institute of Medicine.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlistdistinguished members of the appropriate professions in the examination of policy matters pertain-ing to the health of the public. In this, the Institute acts under both the Academy's 1863 congres-sional charter responsibility to be an adviser to the federal government and its own initiative inidentifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of theInstitute of Medicine.

This project was funded by the Robert Wood Johnson Foundation (Grant No. 20520-R);Metropolitan Life; the American Heart Association; by funds provided by the Cigarette andTobacco Surtax Fund of the State of California through the Tobacco-Related Disease Research Pro-gram (Grant No. 3SP-0416); the Centers for Disease Control and Prevention and the National Insti-tute on Drug Abuse (Grant No. M93-OSH-DASH); the Indian Health Service; the Center forSubstance Abuse Prevention; and the National Cancer Institute, the Maternal and Child HealthBureau of the Health Resources and Services Administration, and the Agency for Health Care Pol-icy and Research (Grant No. I-R13-CA62355-01).Library of Congress Cataloging-in-Publication DataGrowing up tobacco free : preventing nicotine addiction in children and youths / Barbara S. Lynch

and Richard J. Bonnie, editors ; Committee on Preventing Nicotine Addiction in Children andYouths, Institute of Medicine.

First Printing, September 1994

p. cm.Second Printing, January 1996

Includes bibliographical references and index.Third Printing, May 1997

ISBN 0-309-05129-0

Fourth Printing, October 1998

1. Children—Tobacco use—United States—Prevention. 2. Youth—Tobacco use—United States—Prevention. I. Lynch, Barbara S. II. Bonnie, Richard J. III. Institute ofMedicine (U.S.). Committee on Preventing Nicotine Addiction in Children and Youths.

HV5745.G75 1994362.29'67'083—dc20 94-31455

CIPCopyright 1994 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures andreligions since the beginning of recorded history. The image adopted as a logotype by the Instituteof Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen inBerlin.Credit: Cover artist, Juan Morrell, P.S. 54, Brooklyn. Cover poster and additional posters through-out book taken from Kids Say Don't Smoke by Andrew Tobias. Copyright 1991 by Andrew Tobiasand Smokefree Educational Services, Inc. Reprinted by permission of Workman Publishing, NewYork.

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COMMITTEE ON PREVENTING NICOTINE ADDICTIONIN CHILDREN AND YOUTHS

Paul R. Torrens, M.D., M.P.H. (Chair) Professor of Health ServicesAdministration Department of Health Services School of Public HealthUniversity of California, Los Angeles

Albert Bandura, Ph.D. David Starr Jordan Professor of Social Science inPsychology Department of Psychology Stanford University

Neal L. Benowitz, M.D. Professor and Chief Division of ClinicalPharmacology Departments of Medicine, Pharmacy, and Psychiatry Schoolof Medicine University of California, San Francisco

Richard J. Bonnie, LL.B. John S. Battle Professor of Law Director, Institute ofLaw, Psychiatry, and Public Policy University of Virginia School of Law

K. Michael Cummings, Ph.D., M.P.H. Director, Smoking Control ProgramDepartment of Cancer Control and Epidemiology Roswell Park CancerInstitute Buffalo, New York

Donald R. Dexter, Jr., D.M.D. Executive Director Klamath Tribal Health andFamily Services Klamath, Oregon

Ellen R. Gritz, Ph.D. Professor and Chair Department of Behavioral ScienceM.D. Anderson Cancer Center University of Texas, Houston

Gerardo Marín, Ph.D. Professor of Psychology and Associate Dean Collegeof Arts and Sciences University of San Francisco

Mark Nichter, Ph.D., M.P.H. Professor Department of AnthropologyUniversity of Arizona, Tucson

Peggy O'Hara, Ph.D. Associate Professor and Director of Graduate Programsin Public Health Department of Epidemiology and University of MiamiSchool of Medicine

Cheryl L. Perry, Ph.D. Professor Division of Epidemiology School of PublicHealth University of Minnesota

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Thomas C. Schelling, Ph.D. Distinguished Professor of Economics and PublicAffairs School of Public Affairs University of Maryland at College Park

Herbert Severson, Ph.D. Research Scientist Oregon Research Institute andAssociate Professor School of Psychology University of Oregon

Sarah Moody Thomas, Ph.D. Associate Director for Community Educationand Applications Stanley S. Scott Cancer Center Louisiana State UniversityMedical Center

Institute of Medicine Staff

Barbara S. Lynch, Ph.D., Study DirectorRobert Cook-Deegan, M.D., Director, Division of Biomedical Sciences and

Mental DisordersSharon Russell, Project Assistant

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PREFACE

In March 1991, the Institute of Medicine's Board on BiobehavioralSciences and Mental Disorders identified the need for a study on preventingnicotine addiction in children and youths as one of its highest priorities, anddirected the IOM staff to seek the resources required to conduct such a study.The Robert Wood Johnson Foundation generously took the lead in funding theproject, joined by Metropolitan Life, the American Heart Association, theTobacco-Related Disease Research Program (State of California), the Centersfor Disease Control and Prevention, the National Institute on Drug Abuse, theNational Cancer Institute, the Maternal and Child Health Bureau of the HealthResources and Services Administration, the Indian Health Service, the Centerfor Substance Abuse Prevention, and the Agency for Health Care Policy andResearch. In April 1993, a committee of 14 individuals was appointed toconduct an 18-month study on the prevention of nicotine dependence amongchildren and youths, addressing the following tasks:

• to review and evaluate the scientific literature on the epidemiology ofnicotine dependence among children and youths;

• to review and evaluate the scientific literature on primary and secondaryprevention of nicotine dependence among children and youths;

• to review and evaluate the scientific base of knowledge about the causesof nicotine addiction, including physiological, social, psychological,educational, and environmental factors; product advertising andpromotion tactics; and public policy;

• to review important "grass roots" programs on tobacco use and youths; and• to outline a research agenda that makes practical, science-based policy

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recommendations that will contribute to accomplishing the HealthyPeople 2000 Goals of reducing nicotine dependence among children andyouths.

The Committee met five times over the course of the study. It invitedpresentations and written submissions from experts in the field of tobaccocontrol. The Committee also held six focus groups with adolescents in differentgeographical regions. In a cooperative effort with the Coalition for America'sChildren, the Committee conducted a survey of 250 organizations that haveyouth memberships or that serve youths. To assess the level of tobacco-relatedresearch relevant to youths, the Committee contacted federal research agenciesand private foundations to solicit information about their activities related toyouth tobacco use. In addition, the Committee carefully reviewed the extensiveresearch literature on nicotine addiction and youths as well as thecomprehensive summary and analysis of this literature compiled by the surgeongeneral in the 1994 report on smoking and health.1

The relation between scientific knowledge and social policy is oftencomplex and controversial. In this study, however, the Committee's task wasimmensely simplified by the clarity of the nation's public health objectives inrelation to tobacco use. The premises of this report, as discussed in chapter 1,are that the nation has a compelling interest in reducing the morbidity andmortality caused by nicotine addiction, and that nicotine addiction can be mostefficiently reduced in the long run by preventing children and youths from usingtobacco products and from becoming addicted to them. The question is notwhether society should try to prevent tobacco consumption by children andyouths, but rather how this objective should be accomplished. The disputedissues, in short, relate to means, not ends.

Within this framework, the Committee has sought to conduct a rigorousand open-minded inquiry. The Committee has identified the menu of socialinterventions that might be undertaken to prevent nicotine addiction amongchildren and youths and reached a common view regarding the policies andprograms that are likely to be most effective in achieving this goal. These issuesare largely, though not exclusively, scientific ones. The main questions arewhether and to what extent a given policy or program can be expected to reducethe onset of tobacco use and addiction among children and youths. Informedjudgments on these questions provide an essential foundation for prudentpolicymaking and priority-setting.

The Committee could have confined itself to scientific judgments about theefficacy of various policies and programs, leaving to policymakers theevaluative task of weighing the costs of these interventions against anticipatedpublic health gains. However, the Committee was charged with the additionalresponsibility of making "practical science-based policy recommendations thatwill contribute to accomplishing the Year 2000 goals of reducing nicotinedependence among children and youths." The Committee has tried to respond tothis challenge.

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The material in this report is organized as a blueprint for policymaking. Inthe context of each type of intervention, the Committee has summarized thepertinent empirical evidence and sought to demonstrate why, in our opinion, therecommended policies or programs are justified. The Committee did not think itnecessary to duplicate in this report all the information on the etiology ofsmoking by children and youths appearing in the surgeon general's recentreport. Instead, the Committee presents the information bearing most directly onthe potential effects of policies and programs designed to reduce nicotineaddiction among children and youths.

In conducting its study and writing this report, the Committee hasbenefitted immensely from the path-breaking efforts of researchers andpolicymakers in other countries, especially Canada, Australia, New Zealand,and Finland, and from information provided by the World Health Organizationand the International Union Against Cancer. This debt can be partially repaid ifthe proposals made in the report provide a useful model for reformers in otherparts of the globe.

Tobacco use is a worldwide epidemic, and every nation is confronted by achallenge similar to the one faced in the United States. During the 1990s indeveloped countries, tobacco will cause approximately 30% of all deaths amongpersons 35-69 years of age, making it the largest single cause of prematuredeath in the developed world.2 The global health burden of tobacco use is likelyto increase geometrically in the coming decades. It also seems likely thataggressive marketing by the international tobacco companies will require anaggressive response by public health officials in the developing world and in thecountries of Central and Eastern Europe and the former Soviet Union. TheCommittee was not charged to address international tobacco control. In thecourse of its deliberations, however, the Committee unanimously reached theconclusion that decisive actions taken here at home to promote a youth-centeredstrategy to prevent tobacco-related disease and death should be accompanied byan unequivocal commitment to help other nations achieve similar aspirations.

REFERENCES1. Centers for Disease Control and Prevention. Preventing Tobacco Use Among Young People: A

Report of the Surgeon General. Washington, D.C.: U.S. Department of Health and HumanServices, 1994.

2. Peto, Richard, Alan D. Lopez, Jillian Boreham, Michael Thun. and Clark Heath. Jr. "Mortalityfrom Tobacco in Developed Countries: Indirect Estimation from National Vital Statistics."The Lancet 339 (1992): 1268, 1274-1275.

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PREFACE viii

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ACKNOWLEDGMENTS

The Committee on Preventing Nicotine Addiction in Children and Youthsexpresses its appreciation to the co-funders of this 18-month study: the RobertWood Johnson Foundation, Metropolitan Life, the American Heart Association,the Tobacco-Related Disease Research Program of California, the Centers forDisease Control and Prevention, the National Institute on Drug Abuse, theNational Cancer Institute, the Maternal and Child Health Bureau of the HealthResources and Services Administration, the Indian Health Service, the Centerfor Substance Abuse Prevention, and the Agency for Health Care Policy andResearch.

The Institute of Medicine thanks each of the institutions with which theCommittee members are affiliated for the time and support services involved inthe work of the Committee members and in the preparation of the report. TheIOM extends special appreciation to Cornell University School of Law for itsassistance to Richard Bonnie, who was a visiting professor at Cornell during theyear of the Committee's work.

Many persons outside of the Committee contributed to this study invarious ways. The Committee gratefully acknowledges the assistance of thereviewers of the report, as well as the coordinator and monitor of the reviewprocess, all of whom made valuable suggestions for improving the report.Numerous other individuals provided technical information by sendingmaterials, by engaging in telephone discussions, by making presentations to theCommittee, and by writing background papers. The following consultants madepresentations at Committee meetings:

Ron Davis, M.D., Chief Medical Officer, Michigan Department of Health;

ACKNOWLEDGMENTS ix

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Cliff Douglas, Manager, Government Relations, American Cancer Society,Washington, D.C.;

Gary Giovino, Ph.D., Chief, Epidemiology Branch, Office of Smoking andHealth, Centers for Disease Control and Prevention;

Larry Gruder, Ph.D., Director, Tobacco-Related Disease ResearchProgram, University of California, Berkeley;

Don Shopland, Coordinator, Smoking and Tobacco Control Program,National Cancer Institute, Bethesda, Maryland;

John Slade, M.D., Associate Professor of Medicine, St. Peter's MedicalCenter, New Brunswick, New Jersey;

Larry Wallack, Dr. P.H., Professor, School of Public Health, University ofCalifornia, Berkeley.

The following consultants presented commissioned background papers tothe Committee:

Judy Butler, Research Associate, Stanford Center for Research in DiseasePrevention, Stanford University;

Anthony Comerford, New Hope Foundation, Inc., and John Slade, M.D.,St. Peter's Medical Center, New Brunswick, New Jersey;

John Pierce, Ph.D., Associate Professor and Head, Cancer Prevention andControl, University of California, San Diego.

The following research assistants were especially helpful in providinginformation and assistance to the Committee:

Laura Akers, Oregon Research Institute, Eugene, Oregon;Peter Christianns, University of Miami, Department of Public Health;Elizabeth Davidson, University of Virginia, School of Law.Finally, numerous individuals helped expedite preparation of the report by

providing assistance on a temporary or as-needed basis. The Committee thanksKaren Autrey, Jay Ball, Claudia Carl, Holly Dawkins, Mike Edington, LindaHumphrey, Brian Huse, Lynn Leet, Constance Pechura, Zoe Schneider, GailSpears, Nina Spruill, Sally Stanfield, and Mike Stoto.

During the course of the study, the Committee, in conjunction with theCoalition for America's Children, conducted a survey of the coalition's 250member organizations to determine whether they have policies and programsfor tobacco control. The survey provided information about the potential role oforganizations that serve young people. As a means of providing input to theCommittee from experts in the field of substance abuse prevention, the Institutefor Health Promotion and Disease Prevention Research of the University ofSouthern California planned a prevention conference to dovetail with a meetingof the Committee. The presentations and recommendations that were generatedat that meeting were considered by the Committee in its deliberations. As a

ACKNOWLEDGMENTS x

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means of assessing the level and type of research funding that is invested innicotine addiction and tobacco control, the IOM staff conducted a search of allrelevant government agencies and foundations for abstracts describing fundedresearch on nicotine prevention in youths since 1990. A summary of thoseprojects and funds is included in chapter 9. The Committee appreciates theefforts of all persons who made the above surveys and conference possible.

ACKNOWLEDGMENTS xi

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ACKNOWLEDGMENTS xii

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CONTENTS

1 TOWARD A YOUTH-CENTERED PREVENTION POLICY 3

2 THE NATURE OF NICOTINE ADDICTION 29

3 SOCIAL NORMS AND THE ACCEPTABILITY OFTOBACCO USE

71

4 TOBACCO ADVERTISING AND PROMOTION 105

5 PREVENTION AND CESSATION OF TOBACCO USE:RESEARCH-BASED PROGRAM

143

6 TOBACCO TAXATION IN THE UNITED STATES 177

7 YOUTH ACCESS TO TOBACCO PRODUCTS 199

8 REGULATION OF THE LABELING, PACKAGING, ANDCONTENTS OF TOBACCO PRODUCT

233

9 COORDINATION OF POLICIES AND RESEARCH 257

APPENDIXES A Specific Recommendations, by Chapter 281B Committee Biographies 289

INDEX 299

CONTENTS xiii

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CONTENTS xiv

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Craig Perrino, P.S. 50, Staten Island

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TOWARD A YOUTH-CENTERED PREVENTION POLICY




CONTENTS

The Need for a Youth-Centered Tobacco Control Policy 3 Tobacco Use: Addictive and Mostly Initiated During Childhood

and Adolescence 5

Tobacco Use by Children and Youths: No Longer Declining 7 The Emerging Public Health Consensus 9 Public Support for a Youth-Centered Tobacco Control Policy 12 Ethical Foundation of a Youth-Centered Tobacco Control Policy 12 The Elements of a Youth-Centered Tobacco Control Policy 15 Actions That Should Be Taken Immediately 16 Actions Required to Sustain Progress in the Long-Term 21 References 23

CONTENTS 2

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1

TOWARD A YOUTH-CENTEREDPREVENTION POLICY

THE NEED FOR A YOUTH-CENTERED TOBACCOCONTROL POLICY

Use of tobacco products is the nation's deadliest addiction. Smokingcigarettes is the leading cause of avoidable death in the United States. Morethan 400,000 people die prematurely each year from diseases attributable totobacco use.1 The toll of deaths attributable to tobacco use is greater than thecombined toll of deaths from AIDS, car accidents, alcohol, suicides, homicides,fires, and illegal drugs (figure 1-1). Smoking is the main cause of 87% of deathsfrom lung cancer, 30% of all cancer deaths, 82% of deaths from pulmonarydisease, and 21% of deaths from chronic heart disease.2 Use of smokelesstobacco* is a cause of oral cancer.3 In a study of women who did not smoke butdid use snuff chronically, the risk for oral cancers was 50 times greater than fornonusers.4

According to a recent estimate by the Office of Technology Assessment,each smoker who died in 1990 as a result of his or her smoking, on average,would have lived at least 15 additional years if a nonsmoker. (This assumes thatindividuals who die from smoking-related causes would have experienced thelife expectancy of the total population—that is, smokers and nonsmokerscombined—had they not died prematurely.) For the population at large, thispremature mortality translates into 6 million years of potential life lost each year.5

It is difficult, of course, to calculate a dollar value for the human costs of

* The term ''smokeless tobacco" is used in this report to comprise all forms of nasalsnuff, oral snuff, and chewing (spitting) tobacco.

TOWARD A YOUTH-CENTERED PREVENTION POLICY 3

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FIGURE 1-1 Number of deaths per year, 1990. Source: Office on Smokingand Health. Centers for Disease Control and Prevention.


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tobacco-related diseases. The suffering of patients and families resultingfrom tobacco-related morbidity and mortality is unquantifiable. Lostproductivity and health care expenditures can be quantified, but the magnitudeof the estimates depends on a variety of theoretical and technical questions,including whether the costs of health care should be offset by the "savings" insocial security expenditures and health care costs not incurred because peopledied prematurely.6 The Office of Technology Assessment put the social cost ofsmoking in 1990 at $68 billion. This high-end estimate includes $20.8 billion indirect health costs, $6.9 billion in lost productivity attributable to smoking-related disability, and $40.3 billion in lost productivity attributable to smoking-related premature deaths.7 Whatever its total magnitude, the social cost ofsmoking is substantial. Even based on conservative assumptions, expectedlifetime medical expenditures of the average smoker exceed those of theaverage nonsmoker by 28% for men and 21% for women. Each year, decisionsby more than I million youths to become regular smokers commit the healthcare system to $8.2 billion in extra medical expenditures over their lifetimes.8(These figures, which are in 1990 dollars discounted at 3%, reflect the averageexperience in the population of persons who become smokers and take intoaccount variations in the number of years of smoking.)

The nation has a compelling interest in reducing the social burden oftobacco use. This can be accomplished by preventing people from starting touse tobacco and by getting users to quit. The premise of this report is that, in thelong run, tobacco use can be most efficiently reduced through a youth-centeredpolicy aimed at preventing children and adolescents from initiating tobacco use.Moreover, because the prevalence of tobacco use among youths has remainedstubbornly constant for 10 years, and may even be rising, a youth-centeredprevention policy must be aggressively implemented if tobacco-relatedmorbidity and mortality are to be significantly reduced.

Tobacco Use: Addictive and Mostly Initiated DuringChildhood and Adolescence

In 1988, the surgeon general issued a major report demonstrating thatcigarettes and other forms of tobacco are addicting, that most tobacco users usetobacco regularly because they are addicted to nicotine, and that most tobaccousers find it difficult to quit because they are addicted to nicotine. Tobacco useis not a choice like jogging or a habit like eating chocolate; it is an addictionthat is fueled by nicotine.

Most smokers begin smoking during childhood and adolescence, andnicotine addiction begins during the first few years of tobacco use. Moreover,decades of experience in tracking tobacco use show that if people do not beginto use tobacco as youngsters, they are highly unlikely to initiate use as adults.For any cross section of adults who smoke daily, 89% began using cigarettes and


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71% began smoking daily by or at age 18 (figure 1-2).9 In short, decisions byyouths about whether to use tobacco have lifelong consequences. On the onehand, if a person reaches the age of 18 without being a user of tobacco products,he or she is highly unlikely to become a tobacco user during adulthood. On theother hand, most children and youths who initiate regular tobacco use becomeaddicted and their addiction persists for many years thereafter, perhapsthroughout their lives. This is why a youth-centered prevention policy is anessential part of any coherent strategy for countering tobacco-related diseaseand death.

FIGURE 1-2 Source: Data from the National Household Surveys on DrugAbuse, United States, 1991. Office on Smoking and Health. Centers forDisease Control and Prevention.


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Tobacco Use by Children and Youths: No Longer Declining

Since 1964, when the surgeon general called the nation's attention to thehealth hazards of cigarettes, the prevalence of smoking has declinedsubstantially—from 40.4% of the adult population in 1965 to 25.7% in 1991.This trend accelerated between 1987 and 1990, when the rate of smokingamong adults dropped by 1.1% per year, more than double the rate of decreasein the preceding 20 years. Among adults, the number of former smokers (43million) is now nearly that of current smokers (46 million). In fact, among menalive today, more are former smokers than current smokers.10

Despite these impressive successes, the nation's progress towardeliminating tobacco-related disease is in jeopardy. The estimated prevalence ofsmoking among adults appears to have leveled off in 1990 at around 26%(figure 1-3).

FIGURE 1-3 Source: Data from Monitoring the Future Project, 1976-1993,University of Michigan, 1994.


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The use of smokeless tobacco, especially snuff, continues to increase,having tripled between 1972 and 1991. The estimated prevalence of use ofsmokeless tobacco by adults was 2.9% in 1991—5.6% among men and 0.6%among women. Among 18 to 24-year-old men, the rate was 8.2%.11 Unlessthese current trends are reversed, the nation will fall far short of two key Year2000 Health Objectives—a 15% prevalence of regular smoking among adultsand a reduction of smokeless tobacco use by males ages 12-24 to a prevalenceof no more than 4%.12

Why has the momentum toward reducing tobacco use been stalled? Theanswer lies in the replenishment of the tobacco-using population with newrecruits. Despite the marked decline in adult smoking prevalence and theintensifying social disapproval of smoking, it has been estimated that 3,000young people become regular smokers every day.13 According to 1993 datafrom the University of Michigan's Monitoring the Future Study, 29.9% of thenation's high school seniors were current smokers (that is, they smoked withinthe past 30 days) and 19% smoked daily. Among eighth grade students in 1993,16.7% were current smokers and 8.3% smoked daily.14 Estimates of the numberof cigarettes consumed annually by about 3 million children and youths in theUnited States has been estimated conservatively at 516 million packs.15According to the Monitoring the Future Study, in 1993, 10.7% of high schoolseniors were using smokeless tobacco and 3.3% were doing so daily.16 It hasbeen estimated that children and youths consume 26 million containers ofsmokeless tobacco annually.17

The prevalence of smoking by youths has remained basically unchangedsince 1980. Among high school seniors, the prevalence of regular smokers (i.e.,those who have smoked in the past 30 days) was 30.5% in 1980 and 29.9% in1993; the prevalence of daily smokers was 21.3% in 1980 and 19.0% in 1993(figures 1-4 and 1-5). Small increases and decreases occurred in the rates overthe years, but a statistically significant increase of 1.8% in daily smoking from1992-1993 has concerned public health officials.18 Although little use ofsmokeless tobacco was seen among adolescents before 1970, the prevalence ofits use among older teens (16-19 years old) increased nearly 10-fold between1970 and 1985,19 and overall appears to have remained constant since then.20As these trends clearly show, the forces that have been reducing tobacco use byadults—especially getting adults to quit—have not been as effective in reducingthe onset of tobacco use among children and youths.

Beneath these aggregate prevalence figures lies an intriguing reminder ofthe ethnic diversity of American society. Since 1980, while daily smokingprevalence has remained stubbornly high among non-Hispanic white youthswho are high school seniors (22% in 1980, 20% in 1992, and 23% in 1993),there has been a dramatic decline in daily smoking among African-Americanyouths (16% in 1980, to 3.7% in 1992, and 4.4% in 1993).21 Public healthofficials are uncertain about the reasons for these divergent trends among ethnicsubgroups of American youths, and the research needed to clarify those reasonshas not yet


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been done. However, the Committee is hopeful that a tobacco-free norm mayhave taken root among African-American youths. The key questions arewhether this trend will be sustained in the African-American population andwhether well-crafted public policies can extend it to the U.S. population as awhole. In any case, the decline in smoking among African-American youths is abright spot in an otherwise dim picture.

FIGURE 1-4 Source: Data from Monitoring the Future Project, 1976-1993,University of Michigan. Courtesy of Office on Smoking and Health, Centersfor Disease Control and Prevention.

The Emerging Public Health Consensus

There seems to be general agreement among public health officials that


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FIGURE 1-5 Source: Data from Monitoring the Future Project, 1976-1993,University of Michigan. Courtesy of Office on Smoking and Health, Centersfor Disease Control and Prevention.


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aggressive measures will be needed to make a substantial and enduringreduction in the prevalence of tobacco use by America's children and youths.Indeed, public health officials are worried that the incidence of youthfulconsumption will rise unless decisive steps are taken to prevent it. Theseconcerns are rooted in the economics of the tobacco market. Because of theoverall decline in adult consumption, and a significant increase in tobacco taxesover the last few years, the tobacco companies have been competing for sharesof a shrinking market. Declining demand has led to the introduction of genericbrands, discount pricing, and other forms of price competition. It has also led toa remarkable increase in expenditures for advertising and promotion.Collectively, the tobacco industry spent more than $4.6 billion in 1991 toadvertise and promote tobacco products, a 13% increase over 1990expenditures.22 The population of the United States is exposed to this massivearray of pro-tobacco messages every day. Inevitably, these messages "promote"tobacco use to children and youths as well as adults, and to impressionablenonusers of tobacco products as well as users.

The surgeon general has observed that "clearly, young people are beingindoctrinated with tobacco promotion at a susceptible time in their lives."23Many public health officials and observers are convinced that the tobaccoindustry has purposely targeted its promotional activities on youth. TheCommittee is not in a position to assess the intentions of tobacco advertisersand producers, but the ubiquitous display of messages promoting tobacco useclearly fosters an environment in which experimentation by youths is expected,if not implicitly encouraged. This social environment is inimical to the healthand well-being of the nation's children and, ultimately, to the health ofAmerican society. It should be changed. The justification for such a changedoes not depend on proving that makers and sellers of tobacco products intendto induce nicotine addiction among the nation's young people: it is enough thattheir promotional activities make tobacco use seem attractive and have a naturaltendency to trigger a chain of events that has disastrous public healthconsequences in the long run.

In sum, two trends have raised widespread concern among public healthofficials regarding the present status of tobacco control efforts. First, theprevalence of smoking and smokeless tobacco use by youths has remainedstubbornly high while the prevalence of tobacco use by adults has declined.Second, aggressive marketing by the tobacco companies has increased thevolume of pro-tobacco messages at the same time that public health advancesseem to have slowed, or even come to a halt. These combined concerns have ledto a consensus among public health experts that tobacco control efforts mustfocus more heavily on preventing children and youths from using tobaccoproducts and becoming dependent on them. A vigorous effort to preventinitiation of tobacco use by children and youths must be the centerpiece of thenation's tobacco control policy and should be among its highest public healthpriorities.


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Public Support for a Youth-Centered Tobacco Control Policy

A youth-centered tobacco control strategy has broad public support. In anational survey of adults, a majority (73%) favored an increase in the tax oncigarettes as a measure to help finance health care reform. Those who wereopposed to the tax on cigarettes were asked how their support would change ifthe money were used for various other purposes. A majority of that group(73%) said that they would be more likely to support a tax if the money wereused to discourage smoking among young people. Of the entire populationsurveyed, 62% believe that increasing the cigarette tax would discourage youngpeople from starting to smoke, and 76% favor restrictions of cigaretteadvertising that appeals to children.24 Another poll, of U.S. voters, found thatthe most popular restriction on the sales of tobacco products would be a ban oncigarette vending machines: 73% (including 66% of all smokers) said theyfavor banning cigarette machines "in order to make it more difficult for kids toobtain cigarettes."25 Two-thirds of voters favor banning smoking in all publicplaces, such as restaurants, stores, and government buildings—policies thatwould promote a tobacco-free social norm for youths. About two-thirds of thevoters surveyed agree with the assertion that tobacco companies "do everythingthey can to get teenagers and young people to take up smoking."26 In a thirdpoll of smokers, 70% were concerned that their children would eventually startsmoking because they see them smoking, 93% agreed that more should be doneto educate kids about the dangers of cigarettes, and only 17% believed thattobacco manufacturers should be allowed to advertise their products to highschool students or to children (7%).27

Growing public support for youth-centered tobacco control measures isalso reflected in the activity of local advocacy coalitions and in grassrootspolitical action. Hundreds of localities have enacted local ordinances banningvending machines, establishing smoke-free environments in public places, andotherwise promoting a tobacco-free norm.28 Unfortunately, strong grassrootssupport for tobacco control policies at the local level has too often beenneutralized through powerful lobbying by the tobacco industry at the state level,resulting in weak state legislation that preempts more restrictive local measures.Legislative initiatives at local and state levels relating to advertising andpromotion have also been stymied by a preemptive provision of federal law thatprecludes "any requirement or prohibition based on smoking and health." Asdiscussed below, this preemption must be repealed in order to enable state andlocal governments to implement youth-centered tobacco control initiatives andthereby carry out the public will.

Ethical Foundation of a Youth-Centered Tobacco ControlPolicy

A youth-centered tobacco control policy has a firm ethical foundation.American society ordinarily values and respects the prerogative of adults to de


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cide how to live their own lives as long as they do not endanger anyone else. Ifadequately informed, adults are assumed to be capable of making rational andvoluntary choices that involve weighing the risks and benefits of a particularbehavior in light of their own preferences and values. The applicability of theinformed choice model to tobacco use has been a subject of ongoingcontroversy in the literature of applied moral philosophy.29 Although somewriters30 have accepted the possibility of a rational and voluntary choice to usetobacco by adequately informed (and unaddicted) adults, others have pointedout that the onset of addiction compromises the voluntariness of subsequentchoices, even by adults.31 As a practical matter, however, arguments about therationality of choices by adults to initiate tobacco use are beside the pointbecause at least 70% of adult daily smokers already became daily smokers, andpresumably were addicted, by the time they were 18 years old. Thus, the criticalissue is whether children and adolescents are in a position to make informedand rational choices about whether to become tobacco users.

No one argues that preteens have the necessary abilities to make rationalchoices about tobacco use. Yet, as shown in chapter 2, a significant proportionof adult smokers begin using tobacco before becoming teenagers. Data from the1990 Youth Risk Behavior Survey indicate that 56% of youths have triedsmoking and 9% have become regular smokers by age 13.32

Some researchers have suggested that adequately informed adolescents(over age 13) exhibit cognitive decision-making skills similar to those used byyoung adults (through age 25).33 Others have claimed that adolescents are wellinformed about the health risks of tobacco use.34 Even if these controversialassertions were accepted, they do not show that adolescents are in a position tomake sound choices about tobacco use. One must also take into account otherfaulty beliefs held by adolescents regarding the consequences of tobacco use aswell as adolescent tendencies to evaluate and weigh risks and benefits within ashortened time frame.

Adolescent decisions to engage in risky behaviors, including tobacco use,reflect a distinctive focus on short-term benefits and an accompanying tendencyto discount long-term risks or dangers, and to believe that those risks can becontrolled by personal choice. Decision-making deficiencies exhibited bychildren and youths who choose to use tobacco are most evident when theirperceptions and reasoning are compared with the perceptions and reasoning oftheir peers who choose not to use tobacco.

Clearly, youths who choose to use tobacco perceive greater benefitsrelative to risks than youths who choose not to do so.35 What is most striking,however, is the nature of the trade-off. When children and youths begin to usetobacco, they tend to do so for reasons that are transient in nature and closelylinked to specific developmental tasks—for example, to assert independenceand achieve perceived adult status, or to identify with and establish social bondswith peers who use tobacco (see chapters 2 and 3). Youths who smoke or intendto smoke


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tend to be heavily influenced by their perception of potential social benefits andrisks of doing so. Compared with nonsmokers and youths who do not intend tosmoke, smokers and likely smokers tend to exaggerate the social benefit (byoverestimating its prevalence and popularity among peers and adults) and tounderestimate the social risks (by underestimating the prevalence of negativeattitudes toward smoking held by their peers).36

The evidence also shows a tendency among adolescents who have begunto smoke to discount long-term health risks. The issue is not one of generalknowledge. Smokers seem to be aware of the link between tobacco use andvarious diseases, but data consistently show that young smokers, compared withnonsmokers, systematically give less weight to the long-term risks. Forexample, in 1989, only half of high school seniors who smoked (compared withthree-fourths of nonsmokers) reported believing that smoking a pack or moreper day is a serious health risk.37

Adolescent decision-making is plagued especially by the difficulty ofenvisioning long-term consequences and appreciating the personal relevance ofthese consequences. Abundant evidence demonstrates that youths who begin touse tobacco do not understand the nature of addiction and, as a result, believethey will be able to avoid the harmful consequences of tobacco use. Theyunderstand that a lifetime of smoking is dangerous, but they also tend to believethat smoking for a few years will not be harmful, a belief that is less commonamong nonsmokers.38 Among 12- through 18-year-olds in the 1989 TeenageAttitudes and Practices Survey, 21% of smokers (compared with 3% of thosewho never smoked) said they believed that it is safe to smoke for only a year ortwo.39 The key is that many youths who smoke do not expect to smoke over alifetime and, in fact, expect to smoke only for a few years. They believe, inshort, that they can escape the harmful consequences of an admittedly riskypractice. What these youths do not appreciate, of course, is the grip of nicotineaddiction.

Adolescents' failure to appreciate the long-term consequences of decisionsto smoke is explicitly revealed by a longitudinal track of the University ofMichigan's Monitoring the Future Study. As high school seniors, the subjectswere asked ''Do you think you will be smoking cigarettes 5 years from now?"Among respondents who were occasional smokers (less than one cigarette perday), 85% predicted that they probably or definitely would not be smoking in 5years, as did 32% of those who smoked one pack per day. However, at followup5-6 years later, of those who had smoked one pack per day as seniors, only 13%had quit and 70% still smoked one pack or more per day. Of those who smokedoccasionally as seniors, only 58% had quit, but 37% had actually increased theircigarette consumption.40

If a youth decides to begin smoking at the age of 12 or 13, the deficit in hisor her ability to appreciate the long-term risks of doing so is even morepronounced, and more disturbing, than it is at 16 or 17.41 Indeed, it is clear thatthe grip of nicotine addiction is most powerful and most enduring for youths who


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